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2011 KHS Disclosure Statements

2011 KHS Disclosure Statements

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Published by sunnews
The Kitsap Humane Society Board of Directors signed conflict of interest disclosure statements for 2011.
The Kitsap Humane Society Board of Directors signed conflict of interest disclosure statements for 2011.

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Published by: sunnews on Mar 15, 2012
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03/15/2012

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AppendixD
KHSDisclosureStatement
AllBoardMembers,theExecutiveDirector,andSeniorManagersarerequiredtoreviewandsignthisstatementperKHSpolicy.Theyaretocomplete'A'andtheninitialinthespaceattheendof'B'orcompleteitem'C'.A.Myprimarybusinessoroccupationatthistimeis:
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B.
Iamnotawareofanyrelationshiporinterestorsituationinvolvingmyimmediatefamilyormyselfwhichmightresultin,orgivetheappearanceofbeing,aconflictofinterestbetweenmyfamilymemberormeandKHS.C.Thefollowingarerelationships,interestsorsituationsinvolvingmeoranimmediatefamilymemberwhichmightresultin,orappeartobeanactual,apparentorpotentialconflictofinterestwithKHS.For-profitcorporatedirectorships,positionsandemploymentwith:Nonprofittrusteeshipswith:Membershipsinthefollowingorganizations:Contracts,businessactivitiesandinvestmentswith:Otherrelationshipsandactivities:IhavereadandunderstandtheKitsapHumaneSociety'SConflictofInterestandDisclosurePolicyandagreetobeboundbyit.IwillpromptlyinformtheBoardPresidentofanymaterialchangethatdevelopsintheinformationcontainedintheforegoingstatement.
Page4of4
Adopted3/08,Revised9/22/09
 
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AppendixD
KHSDisclosureStatement
AllBoardMembers,theExecutiveDirector,andSeniorManagersarerequiredtoreviewandsignthisstatementperKHSpolicy.Theyaretocomplete'A'andtheninitialinthespaceattheendof
'B'
orcompleteitem'C'.A.Myprimarybusinessoroccupationatthistimeis:
fJ:r~d
B.
I
mnotawareofanyrelationshiporinterestorsituationinvolvingmyimmediatefamilyormyselfwhichmightresultin,orgivetheappear;ceofbeing,aconflictofinterestbetweenmyfamilymemberormeandKHS.,~
/
c.
Thefollowingarerelationships,interestsorsituationsinvolvingmeoranimmediatefamilymemberwhichmightresultin,orappeartobeanactual,apparentorpotentialconflictofinterestwithKHS.For-profitcorporatedirectorships,positionsandemploymentwith:Nonprofittrusteeshipswith:Membershipsinthefollowingorganizations:Contracts,businessactivitiesandinvestmentswith:Otherrelationshipsandactivities:
I
havereadandunderstandtheKitsapHumaneSociety'sConflictofInterestandDisclosurePolicyandagreetobeboundbyit.IwillpromptlyinformtheBoardPresidentofanymaterialchangethatdevelopsintheinformationcontainedintheforegoingstatement.
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Sig~DaterintName
Page4of4Adopted3/08,Revised9/22/09
 
Appendix0
KHSDisclosureStatement
AllBoardMembers,theExecutiveDirector,andSeniorManagersarerequiredtoreviewandsignthisstatementperKHSpolicy.Theyaretocomplete'A'andtheninitialinthespaceattheendof'B'orcompleteitem'C'.A.Myprimarybusinessoroccupationatthistimeis:
B.
Iamnotawareofanyrelationshiporinterestorsituationinvolvingmyimmediatefamilyormyselfwhichmightresultin,orgivetheappearanceofbeing,aconflictofinterestbetweenmyfamilymemberormeandKHS.C.Thefollowingarerelationships,interestsorsituationsinvolvingmeoranimmediatefamilymemberwhichmightresultin,orappeartobeanactual,apparentorpotentialconflictofinterestwithKHS.For-profitcorporatedirectorships,positionsandemploymentwith:
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Nonprofittrusteeshipswith:
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Membershipsinthefollowingorganizations:
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Contracts,businessactivitiesandinvestmentswith:
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Otherrelationshipsandactivities:
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IhavereadandunderstandtheKitsapHumaneSociety'sConflictofInterestandDisclosurePolicyandagreetobeboundbyit.IwillpromptlyinformtheBoardPresidentofanymaterialchangethatdevelopsintheinformationcontainedinheforegoingstatement.
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PrintNameDate
Page40f4Adopted
3/08,
Revised9/22/09

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